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BRISK REFLEXES IN THE LIMBS OF PATIENTS WITH ARTERIOVENOUS FISTULAE
143 in immunisation of various animal species with vaccines against ETEC which used pili or colonisation factors as protective antigensl8suggests that a similar approach could be used to protect man. Before these can be seriously considered the frequency of various colonisation factors of the ETEC affecting manl9needs to be determined. If vaccination against enteric pathogens is to substantially reduce diarrhoeal morbidity and mortality in developing countries, the vaccines must be administered within the first 6 months of life. We believe that priority should be given to the development of vaccines against rotavirus and enterotoxigenic E. coli diarrhoea. success
to
We thank Mr A. Hoque and the field workers of the Matlab research area and Dr K. A. Al Mahmood, Dr A. S. M. Hamidur Rahman, and Mr G Kibnya
for laboratory assistance. Request for reprints should be addressed to R. E. B., Center for Vaccine Development, Bressler Building, Room 400, University of Maryland School ofMedicme, 29 South Greene Street, Baltimore, Maryland 21201, U.S.A. REFERENCES 1. Rowland MGM, Cole TJ, Whitehead RG A quantitative study into the role of infection in determining nutritional status in Gambian village children Br JNutr 1977; 37: 441. 2. Puffer RR, Serrano CV Patterns of mortality in childhood Pan American Health Organisation Scientific Publication no. 262, Washington, D.C., 1973 3. Rhode JE, Northrup RS Taking science where the diarrhea is In: Ciba Foundation Symposium 42 Acute diarrhoea in childhood Amsterdam North Holland, 1976; 339-66 4. Warren K, Walsh J. Selective primary health care an interim strategy for disease control in developing countries. N Engl J Med 1979; 301: 967-74.
Physical Signs BRISK REFLEXES IN THE LIMBS OF PATIENTS WITH ARTERIOVENOUS FISTULAE
G. S. VENABLES
N. E. F. CARTLIDGE
Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP As part of an international collaborative study of nontraumatic coma,’we have examined a number of patients with renal failure. One ofus (N. E. F. C.) noted that some had upper-limb reflex asymmetry, and this appeared to persist after recovery from coma. In each patient the brisker reflexes were found in the limb in which was sited an arteriovenous fistula or shunt. As reflex asymmetry is otherwise a useful sign suggesting a focal central-nervous-system lesion, we have assessed the consistency of this observation.
Twenty patients aged 19 to 52 years (mean 40) requiring long-term maintenance haemodialysis were examined. They had been on haemodialysis for between 1 month and 11 years (mean 36 months) and had used a brachial arteriovenous fistula for between 1 month and 9 years. Tendon reflexes were examined in all patients, particular attention being paid to biceps, brachioradialis, triceps, and finger flexor reflexes in the arms. Reflexes were scored on a three-point scale-brisk,
normal, or reduced. Two patients had
evidence of a uraemic neuropathy with absent tendon reflexes. Eight patients had reflex asymmetry between the two arms. In seven patients the reflexes were brisker on the side in which was sited the functioning brachial fistula, and in one patient brisk reflexes occurred on the opposite side to the fistula. This patient had, until 6 months
vaccine development a WHO memorandum. Bull WHO 1979, 57: 719-34 6 Black RE, Merson MH, Rahman ASMM, Yunus MD, Alim ARMA, Huq I, Yolken RH, Curlin GT. A two year study of bacterial, viral and parasitic agents associated
5. Intestinal immunity and
with diarrhea
in
rural
Bangladesh J Infect Dis (in press)
K, Sarder AM, Becker S, Chen LC. Demographic surveillance system Matlab. Vol. 6 Vital events and migration-1977 International Centre for Diarrhoeal Diseases Research, Bangladesh Scientific Report no 18, 1979. 8. Edwards PR, Ewing WH Identification of enterobacteriaceae Minneapolis. Burgess 7. Samad A, Sheikh
9
Publishing Company, 1972.. Merson MH, Sack RB, Kibriya AKMG, Al Mahmood A, Adamed QS, Huq I. The use of colony pools for diagnosis of enterotoxigenic Escherichia coli diarrhea J Clin
Microbiol 1979, 9: 493-97. 10. Yolken RH, Kim HW, Chen T,
Wyatt RG, Kalica AR, Chanock RM, Kapikian AZ. Enzyme-linked immunoassay (ELISA) for detection of human reovirus-like agent of
infantile gastroenteritis Lancet 1979; ii: 263-66. 11. Yolken RH, Wyatt RG, Kapikian AZ. ELISA for rotavirus. Lancet 1977; ii: 819 12. Mosley WH, Bart KJ, Sommer A. An epidemiological assessment of cholera control programs in rural East Pakistan. Int J Epidemiol 1972, 1: 5-1 13. Mata LJ The children of Santa Maria Cauque. A prospective field study of health and growth Cambridge, Massachusetts MIT Press, 1978, 254-92. 14 Kamath KR, Feldman RA, Sunder Rao PSS, Webb JKG. Infection and disease in a group of South Indian families II General morbidity patterns in families and family members. Am J Epidemiol 1969. 89: 375-83. 15. Wyatt RG, James WD, Bohl EH, Theil KW, Saif LJ, Kalica AR, Greenberg HB, Kapikian AZ, Chanock RM Human rotavirus type 2: Cultivation in vitro Science 1980; 207: 189-91 16 Greenberg HB, Kalica AR, Wyatt RG, Jones RW, Kapikian AZ, Chanock RM Rescue of non-cultivatable human rotavirus by gene reassortment during mixed infection with ts mutants of a cultivatable bovine rotavirus Proc Nat Acad Sci U S.A. (in
press) 17. Kapikian AZ, Wyatt RG, Greenberg HB, Kalica AR, Kim HW, Brandt CD, Rodriguez WJ, Parrott RH, Chanock RM Approaches to immunisation of infants and young children against gastroenteritis due to rotavirus Rev Infect Dis 1980, 2: 459-69 18
19.
WHO Scientific Working Group Escherichia coli diarrhea Bull WHO 1980, 58: 23-26. Levine MM, Rennels MB, Daya V, Hughes TP Hemagglutination and colonisation factors in enterotoxigenic coli that cause diarrhea. J Infect Dis 1980; 141: 733-37.
before, used a fistula in the arm with the brisker reflexes. In six patients all four reflexes examined were brisker on the side containing the fistula, in one the abnormal findings were confined to the brachioradialis and finger flexors, and in another to the finger flexors alone. In none of the patients was reflex asymmetry noted in the legs, and no other neurological abnormalities were detected. Examination of the tendon reflexes is an important part of the assessment of motor function in the unconscious patient, and asymmetry of the tendon reflexes is suggestive of a focal central-nervous-system lesion. The neurologist is often asked to see an unconscious patient in renal failure, and the clinical differentiation between metabolic coma and coma secondary to a focal lesion such as a subdural haematoma can be difficult. We have found that in patients with an arteriovenous fistula reflex asymmetry is not uncommon, and we suggest that it should not be regarded as a sign of centralnervous-system disturbance. We have no satisfactory explanation for our observations, though the most likely cause would be the increased blood flow through the limb with the fistula, producing a rise in the temperature of the limb.2 Though these patients could not be studied blind because the presence of the fistula was obvious, nevertheless the results were striking in that almost half the patients had brisker reflexes on the side of the fistula. We suggest that care needs to be taken in the interpretation of reflex changes in any patient with an arteriovenous fistula. We thank Prof. D. N. S. Kerr and Dr M. K. Ward for allowing us to examine
patients under their care. Requests for reprints should be addressed to G.S.V. REFERENCES 1. Bates D, Caronna JJ, Cartlidge NEF, et al Aprospective study of nontraumatic coma methods and results in 310 patients Ann Neural 1977; 2: 211-20 2. Johnson G, Blythe WB. Hemodynamic effects of arteriovenous shunts used for hemodialysis. Ann Surg 1970; 171: 715-23.
to
We thank Mr A. Hoque and the field workers of the Matlab research area and Dr K. A. Al Mahmood, Dr A. S. M. Hamidur Rahman, and Mr G Kibnya
for laboratory assistance. Request for reprints should be addressed to R. E. B., Center for Vaccine Development, Bressler Building, Room 400, University of Maryland School ofMedicme, 29 South Greene Street, Baltimore, Maryland 21201, U.S.A. REFERENCES 1. Rowland MGM, Cole TJ, Whitehead RG A quantitative study into the role of infection in determining nutritional status in Gambian village children Br JNutr 1977; 37: 441. 2. Puffer RR, Serrano CV Patterns of mortality in childhood Pan American Health Organisation Scientific Publication no. 262, Washington, D.C., 1973 3. Rhode JE, Northrup RS Taking science where the diarrhea is In: Ciba Foundation Symposium 42 Acute diarrhoea in childhood Amsterdam North Holland, 1976; 339-66 4. Warren K, Walsh J. Selective primary health care an interim strategy for disease control in developing countries. N Engl J Med 1979; 301: 967-74.
Physical Signs BRISK REFLEXES IN THE LIMBS OF PATIENTS WITH ARTERIOVENOUS FISTULAE
G. S. VENABLES
N. E. F. CARTLIDGE
Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP As part of an international collaborative study of nontraumatic coma,’we have examined a number of patients with renal failure. One ofus (N. E. F. C.) noted that some had upper-limb reflex asymmetry, and this appeared to persist after recovery from coma. In each patient the brisker reflexes were found in the limb in which was sited an arteriovenous fistula or shunt. As reflex asymmetry is otherwise a useful sign suggesting a focal central-nervous-system lesion, we have assessed the consistency of this observation.
Twenty patients aged 19 to 52 years (mean 40) requiring long-term maintenance haemodialysis were examined. They had been on haemodialysis for between 1 month and 11 years (mean 36 months) and had used a brachial arteriovenous fistula for between 1 month and 9 years. Tendon reflexes were examined in all patients, particular attention being paid to biceps, brachioradialis, triceps, and finger flexor reflexes in the arms. Reflexes were scored on a three-point scale-brisk,
normal, or reduced. Two patients had
evidence of a uraemic neuropathy with absent tendon reflexes. Eight patients had reflex asymmetry between the two arms. In seven patients the reflexes were brisker on the side in which was sited the functioning brachial fistula, and in one patient brisk reflexes occurred on the opposite side to the fistula. This patient had, until 6 months
vaccine development a WHO memorandum. Bull WHO 1979, 57: 719-34 6 Black RE, Merson MH, Rahman ASMM, Yunus MD, Alim ARMA, Huq I, Yolken RH, Curlin GT. A two year study of bacterial, viral and parasitic agents associated
5. Intestinal immunity and
with diarrhea
in
rural
Bangladesh J Infect Dis (in press)
K, Sarder AM, Becker S, Chen LC. Demographic surveillance system Matlab. Vol. 6 Vital events and migration-1977 International Centre for Diarrhoeal Diseases Research, Bangladesh Scientific Report no 18, 1979. 8. Edwards PR, Ewing WH Identification of enterobacteriaceae Minneapolis. Burgess 7. Samad A, Sheikh
9
Publishing Company, 1972.. Merson MH, Sack RB, Kibriya AKMG, Al Mahmood A, Adamed QS, Huq I. The use of colony pools for diagnosis of enterotoxigenic Escherichia coli diarrhea J Clin
Microbiol 1979, 9: 493-97. 10. Yolken RH, Kim HW, Chen T,
Wyatt RG, Kalica AR, Chanock RM, Kapikian AZ. Enzyme-linked immunoassay (ELISA) for detection of human reovirus-like agent of
infantile gastroenteritis Lancet 1979; ii: 263-66. 11. Yolken RH, Wyatt RG, Kapikian AZ. ELISA for rotavirus. Lancet 1977; ii: 819 12. Mosley WH, Bart KJ, Sommer A. An epidemiological assessment of cholera control programs in rural East Pakistan. Int J Epidemiol 1972, 1: 5-1 13. Mata LJ The children of Santa Maria Cauque. A prospective field study of health and growth Cambridge, Massachusetts MIT Press, 1978, 254-92. 14 Kamath KR, Feldman RA, Sunder Rao PSS, Webb JKG. Infection and disease in a group of South Indian families II General morbidity patterns in families and family members. Am J Epidemiol 1969. 89: 375-83. 15. Wyatt RG, James WD, Bohl EH, Theil KW, Saif LJ, Kalica AR, Greenberg HB, Kapikian AZ, Chanock RM Human rotavirus type 2: Cultivation in vitro Science 1980; 207: 189-91 16 Greenberg HB, Kalica AR, Wyatt RG, Jones RW, Kapikian AZ, Chanock RM Rescue of non-cultivatable human rotavirus by gene reassortment during mixed infection with ts mutants of a cultivatable bovine rotavirus Proc Nat Acad Sci U S.A. (in
press) 17. Kapikian AZ, Wyatt RG, Greenberg HB, Kalica AR, Kim HW, Brandt CD, Rodriguez WJ, Parrott RH, Chanock RM Approaches to immunisation of infants and young children against gastroenteritis due to rotavirus Rev Infect Dis 1980, 2: 459-69 18
19.
WHO Scientific Working Group Escherichia coli diarrhea Bull WHO 1980, 58: 23-26. Levine MM, Rennels MB, Daya V, Hughes TP Hemagglutination and colonisation factors in enterotoxigenic coli that cause diarrhea. J Infect Dis 1980; 141: 733-37.
before, used a fistula in the arm with the brisker reflexes. In six patients all four reflexes examined were brisker on the side containing the fistula, in one the abnormal findings were confined to the brachioradialis and finger flexors, and in another to the finger flexors alone. In none of the patients was reflex asymmetry noted in the legs, and no other neurological abnormalities were detected. Examination of the tendon reflexes is an important part of the assessment of motor function in the unconscious patient, and asymmetry of the tendon reflexes is suggestive of a focal central-nervous-system lesion. The neurologist is often asked to see an unconscious patient in renal failure, and the clinical differentiation between metabolic coma and coma secondary to a focal lesion such as a subdural haematoma can be difficult. We have found that in patients with an arteriovenous fistula reflex asymmetry is not uncommon, and we suggest that it should not be regarded as a sign of centralnervous-system disturbance. We have no satisfactory explanation for our observations, though the most likely cause would be the increased blood flow through the limb with the fistula, producing a rise in the temperature of the limb.2 Though these patients could not be studied blind because the presence of the fistula was obvious, nevertheless the results were striking in that almost half the patients had brisker reflexes on the side of the fistula. We suggest that care needs to be taken in the interpretation of reflex changes in any patient with an arteriovenous fistula. We thank Prof. D. N. S. Kerr and Dr M. K. Ward for allowing us to examine
patients under their care. Requests for reprints should be addressed to G.S.V. REFERENCES 1. Bates D, Caronna JJ, Cartlidge NEF, et al Aprospective study of nontraumatic coma methods and results in 310 patients Ann Neural 1977; 2: 211-20 2. Johnson G, Blythe WB. Hemodynamic effects of arteriovenous shunts used for hemodialysis. Ann Surg 1970; 171: 715-23.